What is a good pediatric cough syrup for children?

Honey is the Best Pediatric Cough Syrup for Children

For children with acute cough, honey is the most effective and safest "cough syrup" option, offering more relief than no treatment, diphenhydramine, or placebo, and should be used as first-line therapy for children over 1 year of age. 1, 2, 3, 4

Recommended Treatment Options

First-Line Treatment:

• Honey (for children over 1 year of age) provides superior cough symptom relief compared to no treatment or placebo 2, 3, 4
• Dosing: 2.5 mL of honey before sleep has been shown to effectively alleviate cough symptoms 3
• Honey probably reduces cough frequency and duration better than placebo and many conventional medications 4

Age-Specific Considerations:

• Children under 1 year: Honey should NOT be used due to risk of infant botulism 2
• Children 1-4 years: Honey is the only recommended option, as OTC medications are contraindicated 5, 6
• Children 4-6 years: Honey remains preferred; OTC medications should generally be avoided 5
• Children 6+ years: Honey first-line; OTC medications per package directions only if necessary 5, 6

Medications to AVOID

OTC Cough Medications:

• The American College of Chest Physicians and FDA recommend AGAINST using OTC cough and cold medicines in children under 4 years 1, 5
• OTC cough medications have little to no benefit in controlling acute cough in children but are associated with significant adverse events 1
• Preparations containing antihistamines and dextromethorphan have been associated with adverse events including death from toxicity in young children 1

Specific Medications to Avoid:

• Codeine-containing medications should be avoided due to potential serious side effects, including respiratory distress 1
• Antihistamines have minimal to no efficacy for cough relief in children 1
• Dextromethorphan has limited efficacy and potential for abuse, especially among adolescents 7, 8

Safety Considerations

Adverse Events:

• Honey: Generally well-tolerated with occasional gastrointestinal symptoms (12% vs 11% with placebo) 4
• Dextromethorphan: Associated with nervousness, insomnia, and hyperactivity in approximately 9.3% of children 4
• Diphenhydramine: Can cause somnolence in approximately 7.5% of children 4
• Between 1969 and 2006, there were 54 fatalities associated with decongestants and 69 fatalities associated with antihistamines in children under 6 years 5

Treatment Algorithm

1. Determine child's age:

   • Under 1 year: Supportive care only (hydration, humidification) 2
   • Over 1 year: Proceed to honey therapy 2, 3

2. For children over 1 year with acute cough:

   • Administer 2.5 mL of honey before sleep 3
   • Continue for up to three days 4
   • Monitor for symptom improvement 2

3. If cough persists beyond 4 weeks:

   • Re-evaluate for specific underlying causes 2
   • Consider referral to specialist if appropriate 2

Common Pitfalls to Avoid

• Using OTC cough medications in children under 4 years of age 1, 5
• Administering honey to infants under 1 year of age due to botulism risk 2
• Treating cough symptomatically without considering the underlying cause, especially for chronic cough 1
• Using adult cough management approaches in pediatric patients 2
• Overuse of antibiotics for non-bacterial causes of cough 2

Remember that most acute cough in children is self-limiting and will resolve with supportive care and honey (if age-appropriate). The evidence strongly supports avoiding pharmaceutical cough syrups in favor of honey for symptomatic relief of cough in children.